Over the past decade, bisphosphonate use in patients with various forms of kidney disease has become widespread. The extensive take up-of these agents by nephrologists reflects the twin perceptions that bisphosphonates are generally safe in patients with kidney disease, and that skeletal protection, readily demonstrable in bisphosphonate-treated populations without kidney disease, is also achievable in patients with chronic kidney disease (CKD) and other forms of nephropathy. Unfortunately, both of these perceptions are based on limited evidence and somewhat tenuous extrapolations [ 1 , 2 ].